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Abstract: The patient in this case is an elderly woman who was found to have gallbladder polyp with anorexia, nausea, back swelling and other uncomfortable symptoms 20 days ago, so she came to our hospital. After physical examination, laboratory tests, and combined with the patient’s complaints, she was diagnosed with gallbladder polyp and cholecystitis and treated with surgical resection.
Basic information】Female, 60 years old
Disease Type】Gallbladder polyp, cholecystitis
Hospital】The First Hospital of China Medical University
Date of Consultation】April 2020
Treatment plan】Surgical treatment (laparoscopic cholecystectomy), drug treatment (diazepam injection, atropine sulfate injection, pantoprazole sodium for injection, cefmetazole sodium for injection, mebendazole injection)
[Treatment period] 5 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect】Anorexia, nausea and other uncomfortable symptoms disappeared
I. Initial consultation
The patient had a routine physical examination 20 days ago and found gallbladder polyps combined with cholecystitis. He complained of poor appetite recently, and after eating some fatty food, he would have symptoms such as anorexia and nausea, accompanied by back distension and pain, and anal discharge stopped, but there was no vomiting, diarrhea, or urgency. Today, he came to our hospital. Outpatient examination showed positive epigastric pressure pain, no rebound pain, mainly in the right upper abdomen, negative Murphy’s sign, no palpable enlargement of liver and spleen, no mobile turbid sounds, no percussion pain in the liver and kidney area, normal intestinal sounds, combined with abdominal ultrasound showed limited bulging of the gallbladder wall into the lumen and thickening of the gallbladder wall.
II. Treatment
According to the examination results, the patient and his family were informed of his condition and the available treatment options, and after discussion, it was decided to perform surgical treatment. The patient was operated under general anesthesia with endotracheal intubation. The gallbladder triangle was carefully separated during the operation and the gallbladder was removed smoothly. After the patient returned to the ward safely, he was given pantoprazole sodium for injection to inhibit gastric acid secretion, cefmetazole sodium for injection to combat inflammation, and mebendazole injection to relieve pain.
III. Treatment results
The patient had less intraoperative bleeding and generally good postoperative condition. The catheterization was stopped on the second day, and the incision dressing was dry, without blood and exudate, and the bowel sounds were still acceptable on postoperative examination. Three days after surgery, the incision healed well without redness and swelling and other abnormalities. On the fourth day after surgery, pathological results were returned, suggesting gallbladder polyps and chronic cholecystitis, and the patient recovered well after surgery, with stable vital signs and disappearance of anorexia, nausea, back distension and other uncomfortable symptoms.
IV. Notes
The patient was very happy that his condition improved and his discomfort disappeared, and I was also happy that the patient’s condition improved. I instructed the patient to improve his diet and eat less greasy food, such as animal skin, fatty meat, barbecue, etc., after discharge, because after gallbladder removal, the amount of bile secretion will also be reduced, which is not enough to digest too much fat. Exercise, such as walking, playing Tai Chi, etc., so as not to cause venous thrombosis.
V. Personal insight
Patients with diagnosed gallbladder polyps do not necessarily have to be treated surgically. For some polyps that do not cause discomfort, they can be continuously observed without special treatment. However, if patients like the one in this article have poor appetite, anorexia, nausea and other uncomfortable symptoms, it is recommended to consult a doctor in time, and surgical excision should be performed according to their own situation, so as not to delay the treatment and induce gallbladder stones or even cancer, making treatment more difficult.